From the Guidelines
The recommended first-line antihypertensive treatment for patients with End-Stage Renal Disease (ESRD) is typically a calcium channel blocker (CCB) such as amlodipine (5-10 mg daily) or a beta-blocker such as metoprolol (25-200 mg daily in divided doses). For ESRD patients on dialysis, volume control through appropriate dialysis is actually the cornerstone of blood pressure management, as fluid overload is a major contributor to hypertension in this population. ACE inhibitors and ARBs, while beneficial in earlier stages of kidney disease, are used more cautiously in ESRD due to hyperkalemia risks, though they may still be appropriate in selected patients, particularly those with significant proteinuria or heart failure, as suggested by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) consensus report 1.
Some key points to consider when managing hypertension in ESRD patients include:
- The importance of volume control through dialysis
- The potential benefits and risks of using ACE inhibitors and ARBs in ESRD patients
- The need for individualized treatment based on comorbidities and patient profiles
- The preference for beta-blockers in patients with coronary artery disease and CCBs in patients with certain other conditions, as discussed in the KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease 1.
In terms of specific antihypertensive agents, a recent network meta-analysis by Xie et al. found that both angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) reduced the risk of kidney failure and major cardiovascular events in patients with CKD, although ACEi reduced the odds of all-cause death compared to active control 1. However, the use of these agents in ESRD patients requires careful consideration of the potential risks and benefits.
Overall, the management of hypertension in ESRD patients requires a comprehensive approach that takes into account the individual patient's needs and comorbidities, as well as the potential benefits and risks of different antihypertensive agents.
From the FDA Drug Label
The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).
The recommended first-line antihypertensive treatment for patients with End-Stage Renal Disease (ESRD) is losartan, as it has been shown to reduce the risk of ESRD by 29% in patients with type 2 diabetes and nephropathy 2.
- Key benefits of losartan in ESRD patients include:
- Reduced risk of ESRD
- Reduced risk of doubling of serum creatinine
- Reduced proteinuria
- However, it is essential to note that the study was conducted in patients with type 2 diabetes and nephropathy, and the results may not be directly applicable to all ESRD patients.
From the Research
Antihypertensive Treatment for ESRD Patients
The recommended first-line antihypertensive treatment for patients with End-Stage Renal Disease (ESRD) includes:
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin receptor blockers (ARBs)
- Beta-blockers
These medications are considered reasonable first-line agents for most patients with ESRD, as they have been shown to improve cardiovascular outcomes and reduce mortality risk 3, 4, 5.
Benefits of ACE Inhibitors and ARBs
ACE inhibitors and ARBs have been found to exert cardioprotective effects that are independent of blood pressure reduction, making them a favorable choice for patients with ESRD 6, 4. Additionally, combination treatment of ACE inhibitors and ARBs has been shown to safely retard the progression of non-diabetic renal disease compared to monotherapy 7.
Considerations for Medication Selection
When selecting antihypertensive medications for patients with ESRD, it is essential to consider individual patient comorbidities and the potential for medication removal with dialysis 3. Medications that are removed with dialysis may be preferred in patients who are prone to develop intradialytic hypotension. Furthermore, the association between the use of ACE inhibitors and ARBs and mortality in ESRD patients has been found to be significant, with reduced risk of cardiovascular death and all-cause mortality 4, 5.